Administration Fiscal Year 2019 Presentation to the Appropriations - - PowerPoint PPT Presentation

Behavioral Health and Developmental Disabilities Administration

Fiscal Year 2019

Presentation to the Appropriations Subcommittee on Health & Human Services

Lynda Zeller, Senior Deputy Director, Behavioral Health and Developmental Disabilities Administration Farah A. Hanley, Senior Deputy Director, Financial Operations Administration 1

Presentation Agenda

• HIGHLIGHTED SERVICE STATISTICS
• OVERVIEW: PROGRAMS AND PERSONS SERVED
• Community Based Services
• State Psychiatric Hospitals and Inpatient Units
• FY 2018 STRATEGIC INITIATIVES UPDATES
• FY 2019 EXECUTIVE BUDGET RECOMMENDATIONS

2

Service Statistics

3

• 46 Community Mental Health Services Programs
• 10 Prepaid Inpatient Health Plans
• 228,444 people served by Community Mental Health Services Programs

and Prepaid Inpatient Health Plans in 2016

• 5 state-operated hospitals and centers
• 772 State Hospital census in house (January 24, 2018)
• 2,159 licensed psychiatric adult beds in the community; 260 for

licensed child/adolescent psychiatric beds in the community

• 2,865 complaints received by MDHHS Office of Recipient Rights

from state hospitals in FY17; 446 complaints were investigated and 1,197 interventions were completed

• 5,197 youth diagnosed with Autism and eligible for Applied

Behavioral Analysis Service

• 41.0 percent increase in Certified Behavioral Analyst workforce

(Autism) from FY16 to FY17

• 99.0 percent of discharges from a psychiatric inpatient unit are

seen for Community Mental Health Services Program follow-up care within seven days

• 99.4 percent of mental health consumers received the initial face-

to-face assessment with a professional within 14 days of request

• 31,469 total children with Serious Emotional Disturbance (SED)

were served by the CMHSPs/PIHPs in FY16 according to the 904 report

• In 2017, 24 of 47 Psychosocial Rehabilitation Clubhouses are

internationally accredited compared to 9 in 2015.

• Diversion Pilots showed that post incarceration, care continued at

a rate 19 times greater for CMHSP clients versus non-CMHSP clients.

• 3,293 individuals entering the behavioral health system

identified as Veterans in FY17; 85% were male, 15% female; 52% identified primarily mental health and 48% identified primarily SUD on admission.

• A reported 71,027 persons received substance use disorder

treatment and recovery services in FY17

• 39.4 percent of persons admitted to substance use disorder

treatment in FY17 also had a mental health issue

• In 2003, combined heroin and opioid admissions were less than
• ne-sixth (17%) of all treatment admissions; in 2017, combined

heroin and opioid admissions reached over two-fifths (45%) of all treatment admissions

• 20,471 persons received medication-assisted treatment during

FY17, up from 5,875 during FY06

• $8.7 million received from successful federal grant applications

for substance use disorder prevention and recovery

• 1,200 women reported being pregnant at admission to

substance use disorder treatment in FY17

• Michigan's reported drug-abstinence rate at treatment

discharge exceeded the national average rate by over 3% in FY17

• The reported percentage of persons employed increased 3.2%

during the course of substance use disorder treatment in FY17

• The reported percentage of persons homeless decreased 11.8%

during the course of substance use disorder treatment in FY17

• More than 200,000 persons attended substance abuse

prevention programs in FY17

OVERVIEW: PROGRAMS & PERSONS SERVED

• Community Based Services
• Community Mental Health (CMH) Statistics
• Substance Use Disorder Data and Statistics
• Inpatient Services
• State Psychiatric Inpatient
• Local Psychiatric Inpatient

4

Individuals Served by Michigan’s Community Mental Health System*

MI=Mentally Ill I/DD=Intellectually/Developmentally Disabled

228,444 Total Served in MI’s CMHSPs

5 113,011 49% 32,569 14% 31,469 14% 28,913 13% 16,458 7% 6,024 3% MI Adult Unreported SED Children I/DD Dual Diagnosis (I/DD & MI) Substance Use Disorder

*Source: MDHHS (2017). FY16 Section 904 Boilerplate Report

6

72,619 71,027

50,000 55,000 60,000 65,000 70,000 75,000 80,000 85,000 90,000 FY2006 FY2008 FY2010 FY2012 FY 2014 FY2016

Number Served FY Served

Individuals Served in Substance Use Disorder Treatment, Prevention, & Recovery Systems (FY 2006-FY 2017)*

203,600 persons attended substance abuse prevention programs in FY17 8,174 persons received recovery support services in FY17

Treatment Prevention Recovery

*Source: MDHHS (2017). FY17 Behavioral Health Treatment Episode Dataset

Source: MDHHS (2017). FY05 to FY17 Treatment Episode Dataset.

Heroin and Other Opiates as Primary Addiction-Related Treatment Need on Admission

T rends: Substance Use Disorder T reatment, Prevention, & Recovery Systems – Opioid T reatment Admissions

7

9,601 9,958 9,931 10,365 12,522 11,358 12,563 12,686 13,376 14,646 17,662 23,344 22,082

4,002 4,918 5,603 6,250 7,779 8,448 9,712 9,446 9,270 7,823 8,407 9,129 8,629

• 5,000

10,000 15,000 20,000 25,000

FY2005 FY2006 FY2007 FY2008 FY2009 FY2010 FY2011 FY2012 FY2013 FY 2014 FY2015 FY2016 FY2017

Heroin Other Opiates

BHDDA Revenue Breakdown (FY18)

Community Based Services

8

Distribution by Source

• Medicaid:

– Money flows from MDHHS to PIHPs for all Medicaid-covered lives (8.3% receive CMHSP services vs. 9.4% last year) – Rates must adhere to federal rules – Rate-setting process factors include:

• Programmatic and Demographic Data
• Historical Trends
• Non-benefit costs (e.g., administration, coordination)
• Adjustments (e.g., program changes, health status)
• Medical Loss Ratio
• Risk Adjustment (e.g., prospective or retrospective)

– Individualized unit cost specific to CMHSP based on historical factors (unlike MHPs that utilize a statewide unit cost as a basis)

• Non-Medicaid:

– Federal Grants: federal methodology based on need – GF Mental Health: based on past utilization only – GF SUD: based on need

92.9% 2.5% 4.5% 0.1%

Total Funding: $3.02 Billion*,**

Medicaid/GF Other Federal CMHSP/GF Restricted

*Source: PA 107 of 2017

**Note: 93% of funding is slated for mental health services; 7% is for SUD services

State Hospitals and Centers— Inpatient Census

9

Adult Hospitals (Patients):

• Caro (148)
• Reuther (167)
• Kalamazoo (141)

Forensic (Patients):

• Center for Forensic

Psychiatry (262) Children (Patients):

• Hawthorn (54)

In-house census as of January 24, 2018: 772 Patients

Local Inpatient Licensed Beds (private):

• Adult: 2197 beds; 59

facilities

• Child/Adolescent: 276

beds; 11 facilities State Hospital Beds (public):

• Adult: 720 beds
• Child/Adolescent: 70

beds

10

Total Inpatient Psychiatric Capacity

FY 2018 STRATEGIC INITIATIVES UPDATES

• Fighting the Opioid Crisis
• Increasing Access to Inpatient Psychiatric Care
• Promoting Mental Health Diversion
• Enhancing Mental Health to Children and Families
• Integrating Behavioral and Physical Health
• Other Significant Projects

11

Severity of the Opioid Crisis

12

MDHHS Public Health Approach to Fighting the Opioid Crisis

13

Reduce Supply and Demand Address Co- Occurring Conditions Increase treatment services Increase emergency services

Prevention Early Intervention Treatment

Improve IT Analytics & Surveillance Promote awareness Identify Risk

• f Addiction

& Overdose

Screening Approaches (i.e., SBIRT, DAST-10) Rescue w/Naloxone Stabilize w/MAT Recover w/ CBT & DBT Community Programs Schools Monitor and adjust dosing Reduce Opioid Pill Counts Informed Consent & Treatment Contracts MAPS Narcs Care Narcs Rx MIHIN CC360 Parenting Skills Mentoring Skills Reduce Illicit Rx & Heroin Trafficking Take-back Programs Coping Skills Care Coordination, Collaboration, and Continuity

Treat Pain w/Fewer Opioids

Multimedia Campaigns

Fighting the Opioid Crisis

• MDHHS is engaged in several initiatives to help mitigate the opioid crisis, inclusive of

expanding/utilizing Medicaid services, implementing SAMHSA grants (i.e., block grant and the State Targeted Response grant), and executing recommendations from the Governor’s Task Force.

• SAMHSA State Targeted Response Grant ($16.3 Million), focused on:

– Prevention – Treatment – Recovery

• SAMHSA block grant, is aimed at affecting the following:

– Prescription Drug and Opioid Overdose Prevention – Opioid Overdose Recovery – Innovative Strategies for Enhancing Treatment Services to Pregnant Women – Drug Court Peer Recovery Support

• Michigan is implementing several projects to mitigate issues with Neonatal Abstinence

Syndrome

14

Fighting the Opioid Crisis (continued)

• Recovery Coach Curriculum and Certification

– Policy effective on January 1, 2018 – Formalizes standards for training, certification and practices for Peer Recovery Coaches as established by MDHHS

• Opioid Health Home Pilot

– State Plan Amendment to bolster access to Medication Assisted Treatment for persons with Opioid Use Disorder

• Crosses the “physical and behavioral health systems” by utilizing FQHCs and specialty BH providers
• Utilize a hub and spoke model with Opioid Treatment Programs and Office Based Opioid Treatment providers
• Comprehensive care management and coordination, including the sharing of data amongst participating providers
• Robust provider staffing standards to ensure all facets of care are attended to
• Working with LARA to Update the SUD Administrative Rules

– Initial discussion with LARA and the PIHPs on January 25, 2018

15

Inpatient Psychiatric Capacity Issues

16

• Reduction in Inpatient Psychiatric Beds
• Community hospitals in 1993 vs. 2017:
• 1993: 3,041 adult beds, 729 child/adolescent beds; 2017: 2,197 adult beds, 276 child/adolescent

beds

• Reduction of 28% and 62% for adult and child beds, respectively (34% reduction overall)
• State Hospitals in 1991 vs. 2017:
• 1991: 29 hospitals serving 3,054 residents; 2017: 5 hospitals serving 772 residents
• Reduction of 74% of residents served
• State Hospital Waitlist
• Averages 180 individuals at any given time
• Forensic Capacity
• Competency to Stand Trial Evaluations
• 49 percent increase in court-ordered competency evaluations since 2010
• No commensurate increase in staff/forensic examiners
• Restoration Treatment
• 113 IST-adjudicated criminal defendants awaiting inpatient admission for restoration treatment
• Average wait time for admission is 93-100 days depending on the hospital

Inpatient Psychiatric Capacity Issues (continued)

17

• State Hospital Overtime
• June-August, 2017: number of state hospital workers with greater than 24+ hours of
• vertime grew from 410 to 727
• Inpatient Admission Denials Project
• Analyzing inpatient psychiatric denial data from July to December, 2017
• All 46 CMHSPs and 10 PIHPs have been contacted
• 26 CMHSPs have provided complete data
• The pilot project from PIHP Region 2 showed the following (March 2016 to July 2017):
• 31,107 denials among 1,676 patients (average of 19 denials per patient)
• Most common reason for denial was “At Capacity” (81% of denial reasons)
• Other reasons for denial included “No callback/No response” and “Patient Does Not Fit Milieu”

State Hospital Resource Investments—Workforce

18

• Expanding the Workforce
• Hiring 72 additional staff members at the State Psychiatric Hospitals
• Section 1060 of PA 107 of 2017
• MDHHS, Legislature, and Key Stakeholders working to devise solutions to increase the workforce

at State Psychiatric Hospitals and Centers

• Researching Civil Service Rule Changes to potentially address compensation and overtime issues
• State Loan Repayment Program (SLRP)
• Pediatric inpatient psychiatrists prioritized in 2018
• MDHHS waived certain SLRP requirements to promote psychiatric provider participation
• Telemedicine
• Formalized the use of telemedicine practice within community based Assertive Community

Treatment to ensure psychiatric services are available

State Hospital Resource Investments—Facilities

19

• Caro Center Replacement
• Construct a new 200-bed replacement facility for the Caro Center (50 bed net increase)
• Integrated Design Solutions was chosen for the design and construction of a new

Caro Center replacement facility

• Design Development intended to be completed in December, 2018
• Project completion estimated for 2021

Michigan Inpatient Psychiatric Access Discussion (MIPAD)

• Priorities of the Short-Term Recommendations:

– Encouraging the Development of Specialty Units for Children – Addressing EMTALA Concerns in Emergency Departments – Standardizing Clinical Processes for Accessing Inpatient Psychiatric Services – Implementing Changes to Financing and Reimbursement for Inpatient Psychiatric Services – Developing a Psychiatric Bed Registry in Michigan

20

Inpatient Alternatives for Children

• Children’s Transition Support Team:

– Currently 32 children/youth are served representing 18 counties – Of the 16 youth discharged 100% remain in the community – No youth are in juvenile detention – As of January 12, 2018, a total of 81 children/youth have received CTST services – Psychiatric hospital re-admission days reduced 60-85%

• Hawthorn Center Transition Program:

– Served 52 youth with serious emotional disturbances in the past year – All youth have transitioned back into the community – There have been no re-hospitalizations – Patient and family surveys all very positive

21

Mental Health Diversion Council Report

• Released on January 22, 2018:

https://content.govdelivery.com/attachments/MIGOV/2018/01/22/file_attachments/946505/Diversion.Council.Progress.Report.pdf

• Highlights key findings and initiatives over the past 18 months, including:

– Mental Health and Criminal Justice Strategic Planning Summit (page 14) – Outcome Report on the pilots affiliated with the Mental Health Diversion Council with stats (page 7)* – Effective enactment of the revised Kevin’s Law February 14, 2017 (page 16) – Michigan Juvenile Justice Assessment System (MJJAS) as the standard assessment tool being used across the state (page 9) – Juvenile Urgent Response Team pilots in Houghton and Muskegon (page 9) – Expanded law enforcement training endorsed by the Diversion Council [Managing Mental Health Crisis 2 day trainings] (page 13) – Crisis Intervention Team Trainings key stats from the pilots (page 7) – Juvenile Justice Report on defining recidivism (page 9) – Expanding initiatives from across the pilot sites (page 11) – MSU citing community relationships being key to pilots success (page 16)

*Diversion Pilots showed that post incarceration, care continued at a rate 19 times greater for CMHSP clients versus non-CMHSP clients

Governor’s Mental Health Diversion Council

22

23

Autism Services

Autism Applied Behavior Analysis (ABA) – Medicaid

1,607 3,859 5,197 1,430 (89%) 1,705 (44%) 1,931 (37%) 177 (11%) 2,154 (56%) 3,266 (63%)

1000 2000 3000 4000 5000 6000

Jan-16 Apr-16 Jul-16 Oct-16 Jan-17 Apr-17 Jul-17 Oct-17

ABA Enrollment Per Month, January 2016-December 2017

Total Enrolled Ages 0-5 Ages 6-20

• 2017 Experienced 34% Increase of Beneficiaries with Medical Necessity for ABA Services

• Additional Need for Certified Behavior Analysts

– Medicaid has 68% (3,534) of youth eligible to receive ABA waiting for appropriate services – 39% (2,027) youth are receiving less ABA services than approved – 29% (1,507) youth are waiting to start ABA services

• Certified Behavior Analysts:
• 685 in Michigan
• 41% increase from 2016 (485)
• Michigan is listed 10th in United States with ABA Providers
• University Autism Contract Accomplishments

– Increase in number of University Autism Training Programs

Autism Services: FY 2018 Initiatives

Autism Applied Behavior Analysis Workforce Capacity

24

25

• Home-Based Services Programs

– 10,240 children received home-based services*, and; – 31,469 children with SED were served* – 75 enrolled CMHSP programs

• Wraparound Services

– 2,062 children with SED received wraparound services* – Significant clinical improvement in functioning before and after service (FY17):

• 60 percent improvement for children aged 0-6
• 72 percent improvement for children aged 7-19

Home Based and Wraparound Services

*Source: MDHHS (2017). FY16 Section 904 Boilerplate Report

Integrating Behavioral and Physical Health

26

• MDHHS has a myriad of behavioral health integration projects, including:
• MI Care Team – serving over 3,000 Medicaid beneficiaries in Michigan’s FQHCs, specifically aimed at those with

depression and/or anxiety in addition to a physical chronic condition

• Opioid Health Home – pilot to serve individuals with Opioid Use Disorder in Michigan’s PIHP Region 2 (described in

earlier slide)

• SIM PCMH and CHIR programs – integrating service delivery and enhancing care coordination between physical and

behavioral health providers

• Utilizing SAMHSA Block Grant funds to support integration activities within and outside of the PIHP structure
• Partnering with the University of Michigan to continue the Collaborative Care Model focused on direct behavioral

health integration

• Developing a more robust set of contractual joint-metrics for the PIHPs and MHPs, some of which will be utilized for

performance bonuses or withholds

• Section 298 of PA 107 of 2017 – development of financially integrated pilots to provide primary and behavioral health

care services through the MHPs

Other Significant FY 2018 Projects

• Managed Care Rule Implementation

– BHDDA and MSA staff are working together to implement all elements of the CMS Managed Care Rule

• Parity

– MDHHS planning to ensure compliance with the federal Mental Health Parity and Addiction Equity Act (MHPAEA)

• Home and Community Based Services (HCBS) Rule

– BHDDA in conjunction with the PIHPs have implemented a transition plan for providers of Home and Community Based Services to meet the requirements of the new federal rule

• Electronic Visit Verification (EVV) Requirements of the 21st Century Cures Act

– Required compliance for Medicaid waiver programs containing personal care services by January 1, 2019

• Veteran and Military Members Strategic Plan

– Embedding Regional Veteran Navigators in all 10 PIHP Regions

• Mental Health & Wellness Commission

– Michigan Child Collaborative Care (MC3) – Special Olympics United Champion Schools (formerly Project UNIFY) – Project SEARCH

27

28

Governor Snyder’s FY19 Recommendation

MDHHS 2019 Highlights

State Hospitals and Centers

• $1.4 M to provide an increase in base salaries for state

psychiatrists

29

5-Year History of Major Line Item Appropriations: State Hospitals

(in millions)

30

Appropriation FY 2015 Expenditures FY 2016 Expenditures FY 2017 Expenditures FY 2018 Enacted FY 2019 Executive Recommendation Center For Forensic Psychiatry $72.7 $71.5 $81.7 $82.8 $94.7 Walter P . Reuther Psychiatric Hospital $49.1 $50.2 $56.9 $59.6 $57.7 Hawthorn Center $23.4 $24.0 $29.1 $31.8 $32.2 Caro Regional Mental Health Center $48.0 $47.3 $57.3 $59.2 $53.5 Kalamazoo Psychiatric Hospital $59.3 $59.4 $65.7 $68.1 $69.5

5-Year History of Major Line Item Appropriations: Medicaid funded Services

(in millions)

31

Appropriation FY 2015 Expenditures FY 2016 Expenditure s FY 2017 Expenditures FY 2018 Enacted FY 2019 Executive Recommendatio n

Medicaid Mental Health Services $2,311.3 $2,388.9 $2,337.0 $2,315.6 $2,364.0 Medicaid Substance Use Disorder Services $47.3 $53.2 $53.4 $52.4 $68.4 Healthy Michigan Plan – Behavioral Health $292.9 $222.6 $247.8 $288.7 $293.0 Autism Services $40.1 $70.0 $61.2 $105.1 $199.8 Community Mental Health Non-Medicaid $117.0 $117.0 $119.9 $120.1 $120.1